The Role of the Anesthesiologist in Management of Obstetric Hemorrhage

https://doi.org/10.1053/j.semperi.2008.12.005Get rights and content

Hemorrhage after childbirth, whether the delivery is vaginal or operative, is a clinical situation where knowledge, communication, and the availability and utilization of resources all play prominent roles. In this article we describe the thought processes and decisions that should occur, and the actions that should be taken by the anesthesiologist in the face of suspected, expected, or unexpected hemorrhage in the labor and delivery suite.

Section snippets

Unexpected Obstetric Hemorrhage

The clinical scenario we are discussing in this section is when the anesthesiologist is called to see and assume care for a patient with an unexpectedly high blood loss after a vaginal delivery. The approach and issues are similar when the bleeding occurs during an expected routine cesarean delivery, but during a cesarean delivery, the anesthesiologist is already present, usually more prepared and certainly more familiar with the patient. It is our experience that more confusion,

High-Risk: “Expected” Hemorrhage

The advent of ultrasound and other advances in imaging have resulted in improved and increased antepartum diagnosis of a variety of conditions associated with increased risk for bleeding, including placenta previa, placenta accreta, vasa previa, etc.15 Placenta accreta (and especially increta/percreta) ranks chief among these conditions in risk for massive, sometimes uncontrollable blood loss. Ninety percent of patients with placenta percreta will lose more than 3000 mL at cesarean

Transfusion Therapy

Regardless of the mode of anesthesia used for these cases, it is prudent to have sufficient blood products immediately available. All blood components are screened (checked) by two people to confirm that products are correctly paired to the patient before the patient is brought to the operating room. Our standard practice for cases with large anticipated blood loss (eg, suspected placenta percreta) is to keep 20 U of cross-matched PRBCs and 20 U of FFP in a refrigerator or cooler in the OR

Cell Salvage in Obstetrics

There are many reasons to consider or favor cell salvage and reinfusion techniques in the case of major hemorrhage. The cost of cell salvage is less than that of obtaining and processing homologous (blood bank) blood; there is no risk of incompatible transfusion or similar transfusion reactions; the risk of infection is reduced; and the blood available may bridge those periods when the blood bank delivery of product “falls behind” the blood loss. Cell salvage may be particularly useful in cases

Conclusion

The anesthesiologist should play a key role in the management of obstetric hemorrhage. As with almost all medical and surgical crises or emergencies, the principles of preparation and planning when possible, early notification when necessary, and good communication and teamwork at all times are the keys to successful outcomes.

References (52)

  • W. Camann

    Cell salvage during cesarean delivery: Is it safe and valuable? Maybe, maybe not!

    Int J Obstet Anesth

    (1999)
  • J. Allam et al.

    Cell salvage in obstetrics

    Int J Obstet Anesth

    (2008)
  • S. Catling

    Blood conservation techniques in obstetrics: A UK perspective

    Int J Obstet Anesth

    (2007)
  • L.S. Bouma et al.

    Use of recombinant activated factor VII in massive postpartum haemorrhage

    Eur J Obstet Gynecol Reprod Biol

    (2008)
  • N.M. Estella et al.

    Normovolemic hemodilution before cesarean hysterectomy for placenta percreta

    Obstet Gynecol

    (1997)
  • C.J. Nagy et al.

    Acute normovolemic hemodilution, intraoperative cell salvage and PulseCO hemodynamic monitoring in a Jehovah's Witness with placenta percreta

    Int J Obstet Anesth

    (2008)
  • R. Fowler et al.

    The role of intraosseous vascular access in the out-of-hospital environment (resource document to NAEMSP position statement)

    Prehosp Emerg Care

    (2007)
  • C. Larsson et al.

    Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration

    Acta Obstet Gynecol Scand

    (2006)
  • S. Maslovitz et al.

    Improved accuracy of postpartum blood loss estimation as assessed by simulation

    Acta Obstet Gynecol Scand

    (2008)
  • W.C. Moloney et al.

    Management of the obstetrical patient with hemorrhage due to an acute or subacute defibrination syndrome

    Blood

    (1959)
  • J.C. Carvalho et al.

    Oxytocin requirements at elective cesarean delivery: A dose-finding study

    Obstet Gynecol

    (2004)
  • M. Balki et al.

    Minimum oxytocin dose requirement after cesarean delivery for labor arrest

    Obstet Gynecol

    (2006)
  • S. Wray

    Uterine contraction and physiological mechanisms of modulation

    Am J Physiol

    (1993)
  • W. Henrich et al.

    Diagnosis and treatment of peripartum bleeding

    J Perinat Med

    (2008)
  • T.A. Thomas et al.

    Deaths associated with anaesthesia

  • A. Meirhaeghe et al.

    The human G-protein beta3 subunit C825T polymorphism is associated with coronary artery vasoconstriction

    Eur Heart J

    (2001)
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